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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACIL1ITY <br />LOCATED AT '3330 tT , 6<-_ <br />(Street Address)+ ,, (City) <br />HEREBY AUTHORIZE T � l W� �0 +�� �(� Lq B 0e2 0 R ��y2> (1 <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />VT TeTArcce XT a NAV. J /.i.(?.,f l)'L �.- rAm....,J).. A _r*rr_,, L <br />(If Applicable) <br />E c4' "/ <br />>> <br />OWNER/OPERATOR: <br />(Please Print <br />(Title) <br />Signature) <br />(Date) <br />ADDRESS: 0 (`_.�f7 AY7-'rG�-t°� <br />(Mailing Address) <br />I� r� A <br />(City) (State) (Zip Code) <br />PHONE:( aal ) <br />I q3 - �6 ((,p <br />EH 23 046 (Revised 10/19/98) Page 9 <br />